Winnfield Nursing And Rehabilitation Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Winnfield, Louisiana.
- Location
- 915 1st Street, Winnfield, Louisiana 71483
- CMS Provider Number
- 195454
- Inspections on file
- 29
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Winnfield Nursing And Rehabilitation Center, Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses was not assisted to the dining room for meals as required by their care plan, despite being dependent on staff for eating and mobility. Staff interviews and observations confirmed that the resident remained in their room during meals, contrary to documented fall prevention measures.
The facility did not ensure that two residents' discharges were properly documented or that written instructions and discharge planning were provided, including the basis for discharge, medication reconciliation, and referrals for caregiver support. Staff interviews confirmed that required discharge documentation and procedures were not completed.
Two residents were discharged without complete discharge summaries, missing required information such as a recapitulation of their stay, final status at discharge, and medication reconciliation. Documentation was either incomplete or missing key details, and staff confirmed that the necessary discharge information was not provided or properly recorded.
A resident with a history of substance use and multiple behavioral health diagnoses was not care-planned for substance abuse, and ongoing concerns about drug diversion and active substance use were not addressed by staff. Provider notes documented the resident's diversion and abuse of medications, but these issues were not acted upon, and required monthly urine drug screens were not performed as ordered.
A resident's admission and Quarterly MDS assessments failed to accurately reflect their diagnoses of PTSD, history of suicidal behaviors, suicidal ideations, and substance use/abuse, despite these being documented in the medical record and social services assessments. Staff interviews confirmed the omissions and acknowledged that these conditions should have been included in the MDS.
A resident with multiple behavioral health diagnoses was admitted without a baseline care plan being developed within 48 hours, as required by facility policy. The DON confirmed that no baseline care plan was created to address the resident's immediate needs after admission.
A resident with multiple behavioral health diagnoses, including substance abuse, suicidal ideations, and PTSD, was not provided with a comprehensive, person-centered care plan addressing these conditions. Staff confirmed that the care plan did not include interventions for these significant issues, contrary to facility policy.
A resident with multiple mental health diagnoses and a history of substance abuse was not referred for mental health services upon admission, despite facility protocols and identified needs. The resident did not receive timely or ongoing mental health evaluations, with gaps in monthly follow-up visits while on antipsychotic and antidepressant medications.
A resident with moderate cognitive impairment was physically abused by another resident during breakfast. The aggressor, also with moderate cognitive impairment, hit the victim in the face after a dispute over milk. The incident was witnessed by CNAs, and the facility's abuse prevention policy failed to prevent this occurrence.
The facility did not meet residents' nutritional needs by failing to serve the correct portion sizes as per the menu. During lunch, six residents on a regular diet received improper portions, with five receiving one small chicken leg and one receiving two small chicken legs, which were not a double portion. The menu specified a 3 oz. portion size for Baked Chicken, but the served portions were inadequate. This was confirmed by the Dietary Manager and Regional Director of Nutritional Services.
The facility failed to adhere to professional food safety standards, as evidenced by moldy bread, expired hot dog buns, and undated cornstarch in the dry storage area, along with an unsealed, undated pad of butter in the refrigerator. These deficiencies were observed with the Dietary Manager and could impact any resident consuming meals from the kitchen.
A resident with legal blindness and cognitive impairments did not have a call light within reach, as required by her care plan. Observations showed the call bell was placed across the room, and staff interviews confirmed the issue was due to the absence of an extension cord. The resident had to yell to communicate her needs.
A resident with mental health disorders was physically abused by another resident with a history of altercations. The incident occurred when one resident tapped the other on the shoulder, leading to a physical altercation. Despite the facility's policy on abuse prevention, the measures in place were insufficient to prevent the incident.
The facility did not thoroughly investigate an incident where a resident tapped another, leading to a physical altercation. Witness statements from staff present during the incident were not obtained, and necessary safety checks on the behavioral unit were not conducted. The administrator confirmed the investigation was incomplete.
A resident with dementia and depression experienced significant weight loss due to the facility's failure to document meal intake and provide one-on-one dining assistance as care planned. Observations showed the resident eating unsafely without supervision, and the DON acknowledged the lack of documentation and assistance.
A resident with multiple diagnoses, including Down's Syndrome and Dementia, was observed with long chin hairs over several days, despite regular bathing and no refusal of care. Staff acknowledged the need for shaving, but the issue persisted, impacting the resident's dignity and quality of life.
The facility failed to implement care plans for two residents, leading to a deficiency in monitoring and recording food intake. One resident, with severe cognitive impairment, experienced a 17% weight loss over three months due to unrecorded meal intake on 36 out of 39 days. Another resident, with dementia and intellectual disabilities, had a 12% weight loss over four months, with meal intake unrecorded on 32 out of 39 days. The DON acknowledged the failure to document as required.
A resident with moderate cognitive impairment and impaired mobility was found with a broken self-release belt buckle on his wheelchair. Despite reporting the issue to a nurse, the broken buckle was observed on multiple occasions, and staff confirmed the failure to address the problem promptly.
Failure to Implement Person-Centered Care Plan for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for one resident with multiple complex diagnoses, including schizoaffective disorder, bipolar type, type 2 diabetes, hypertensive heart disease, anxiety, a history of falling, and dementia with agitation. The resident was assessed as having severe cognitive impairment and was dependent on staff for eating, mobility, transfers, and personal hygiene. The care plan specifically instructed that the resident should be assisted to the dining room for all meals as part of fall prevention measures. Despite these documented care plan instructions, observations and staff interviews confirmed that the resident was not assisted to the dining room for breakfast or lunch on the day in question. The resident was found in her room with a lunch tray, having only consumed milk and leaving the rest of the food untouched. Multiple staff members, including CNAs and an LPN, acknowledged that the resident should have been assisted to the dining room for meals but was not, in direct contradiction to the care plan.
Failure to Document and Prepare Safe Resident Discharges
Penalty
Summary
The facility failed to ensure proper documentation and preparation for the discharge of two residents, as required by its own policies and regulatory standards. For both residents, there was no documentation in the medical record specifying the basis for their discharge, nor evidence that written discharge instructions were provided to or discussed with the residents or their responsible parties. Additionally, there was no documentation of discharge planning that addressed caregiver support or referrals to local contact agencies, despite the facility's policy requiring such actions. One resident, admitted with multiple complex diagnoses including a right tibia fracture, MRSA infection, diabetes, and a history of venous thrombosis, was noted to have intact cognition and expressed a desire to return home. The resident's insurance coverage ended, and although the resident was informed of the option to pay out of pocket, this discussion and the resident's refusal were not documented. The discharge form was only partially completed, and there was no record of medication reconciliation, discharge instructions, or coordination of care in the resident's file. The second resident, admitted for short-term therapy following a stroke and with diagnoses including Alzheimer's disease and hemiplegia, also had no documentation in the medical record regarding the reason for discharge or any instructions about medications provided at discharge. Progress notes indicated the resident was discharged home with medications and that a follow-up evaluation was planned, but there was no evidence of written instructions or comprehensive discharge planning. Interviews with facility staff confirmed that required documentation and discharge procedures were not completed for either resident.
Incomplete Discharge Summaries and Missing Required Documentation
Penalty
Summary
The facility failed to provide complete and compliant discharge summaries for two of three residents reviewed for discharge. For both residents, the discharge summaries were missing essential elements required by facility policy and federal regulations, including a recapitulation of the residents' stay with diagnoses, course of illness or treatment, pertinent lab, radiology, and consultation results, a final summary of the residents' status at the time of discharge, and a reconciliation of all pre-discharge medications with post-discharge medications. For one resident, the medical record review showed an incomplete discharge summary document, lacking the required information and only partially filled out. The document was provided to the resident at discharge, but it did not include a comprehensive summary of the resident's stay, status at discharge, or medication reconciliation. Interviews with facility staff confirmed that the discharge summary was not completed as required and that the responsibility for discharge documentation was not clearly followed. For the second resident, the discharge documentation included a progress note and a discharge summary form, but these also lacked critical information. There was no documentation of the reason for discharge, no list of medications provided at discharge, and no record of instructions given to the resident. The discharge summary form was not signed by the resident and did not include a summary of the resident's diagnoses, treatment course, or status at discharge. Staff interviews confirmed these omissions and acknowledged that the required documentation was not present in the resident's medical record.
Failure to Provide Behavioral Health Services and Monitor Substance Use
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a documented history of substance use and multiple behavioral health diagnoses, including adverse effects of methamphetamines, cannabis abuse, suicidal ideations, PTSD, generalized anxiety disorder, bipolar disorder, and major depressive disorder. The resident's comprehensive care plan did not address their history of substance use/abuse, despite this being known at admission and confirmed by both the administrator and MDS coordinator. Additionally, the resident's Minimum Data Set (MDS) assessments did not indicate substance use/abuse or PTSD, contrary to the resident's medical history. Provider progress notes documented ongoing concerns, including drug diversion, active substance abuse within the facility, and the resident taking medications not prescribed to them. These concerns were not addressed by facility staff, and the administrator was unaware of these issues at the time of the resident's death. Furthermore, although there was a physician's order for monthly urine drug screens (UDS), these were not performed as ordered after the initial positive result for methamphetamine. Staff interviews confirmed that the required monthly UDS were not completed.
Inaccurate MDS Assessments for Resident with Psychiatric and Substance Use History
Penalty
Summary
The facility failed to ensure that both the admission and Quarterly Minimum Data Set (MDS) assessments accurately reflected a resident's clinical status. Specifically, the MDS assessments did not include the resident's diagnoses of PTSD, history of suicidal behaviors, suicidal ideations, or substance use/abuse, despite these being documented in the resident's medical record and social services assessments. The resident's admission and Quarterly MDS both recorded a BIMS score indicating intact cognition and omitted critical psychiatric and substance use diagnoses. Interviews with facility staff confirmed that the resident's social services history and initial assessment identified PTSD, increased anxiety, and a history of substance use/abuse, but these were not reflected in the MDS assessments. The omission was acknowledged by both the Social Services Director and the Administrator, who confirmed that the relevant diagnoses and history should have been included in the MDS documentation.
Failure to Develop Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. According to the facility's policy, a baseline care plan is required to be created promptly upon admission to address the resident's immediate needs until a comprehensive care plan is completed. Record review showed that the resident, admitted with multiple complex diagnoses including adverse effects of methamphetamines, cannabis abuse with intoxication, suicidal ideations, history of suicidal behavior, PTSD, generalized anxiety disorder, bipolar disorder, and major depressive disorder, did not have a baseline care plan in place. During an interview, the Director of Nursing confirmed that a baseline care plan was not developed for this resident, despite policy requirements.
Failure to Develop Comprehensive Care Plan for Resident with Complex Behavioral Health Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident, as required by its own policy. The resident was admitted with multiple diagnoses, including adverse effects of methamphetamines, cannabis abuse with intoxication, suicidal ideations, a history of suicidal behavior, PTSD, generalized anxiety disorder, bipolar disorder, and major depressive disorder. Review of the resident's medical record and care plan revealed that the care plan did not address suicidal ideations, history of suicidal behavior, PTSD, or substance use/abuse. Facility staff interviews confirmed that these issues were not included in the care plan, despite the expectation that they should have been.
Failure to Provide Timely and Ongoing Mental Health Services
Penalty
Summary
The facility failed to provide mental health services in accordance with professional standards for a resident admitted with multiple mental health diagnoses, including PTSD, generalized anxiety disorder, bipolar disorder, major depressive disorder, and a history of substance abuse and suicidal behavior. Upon admission, the resident's social services assessment identified significant mental health needs, but a timely referral for mental health services was not made. Although facility protocol required automatic referral for residents with mental health diagnoses, this was not followed, and the resident was not referred for mental health services until several weeks after admission. Additionally, the facility did not ensure that mental health services were provided on a continual basis. After the initial psychiatric evaluation and two follow-up visits, there were no further mental health encounters documented for the resident, despite ongoing use of antipsychotic and antidepressant medications. Staff interviews confirmed that the resident should have been seen monthly by the mental health nurse practitioner, but this did not occur after the last documented visit.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #3, who has a history of schizoaffective disorder, bipolar type, anxiety disorder, major depressive disorder, depression, glaucoma, legal blindness, and cognitive communication deficit, was involved in an incident with Resident #5. Resident #3 has a BIMS score indicating moderate cognitive impairment. During breakfast, Resident #3 accused Resident #5 of taking her milk, which led to Resident #5 physically hitting Resident #3 in the face. This incident was witnessed by two CNAs who were present in the dining room. Resident #5, who also has a history of schizoaffective disorder, depressive type, anxiety disorder, diffuse traumatic brain injury, and cognitive social or emotional deficit following cerebrovascular disease, was identified as the aggressor in this incident. Resident #5 has a BIMS score indicating moderate cognitive impairment. The facility's incident report and witness statements confirm that Resident #5 made contact with Resident #3's face with her fist, resulting in discoloration to Resident #3's upper lip. The facility's policy on abuse prevention was not effectively implemented to prevent this incident of resident-to-resident abuse.
Failure to Meet Nutritional Needs Due to Improper Portion Sizes
Penalty
Summary
The facility failed to meet the nutritional needs of residents by not adhering to the established portion sizes as outlined in the menu. During an observation of lunch preparation, it was noted that six residents on a regular diet were served improper portion sizes. Specifically, five residents received only one small chicken leg, and one resident received two small chicken legs, which were incorrectly considered a double portion. According to the facility's Production Sheet Main Menu, the portion size for Baked Chicken was specified as 3 oz. An interview with the Dietary Manager and the Regional Director of Nutritional Services confirmed that one chicken leg without the bone was approximately 2 oz., and residents should have been served two chicken legs to meet the 3 oz. portion size requirement.
Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety. During an observation of the kitchen's dry food storage area, a loaf of bread with mold was found, along with two packages of hot dog buns that had expired. Additionally, an opened and undated box of cornstarch was discovered. In the walk-in refrigerator, a used pad of butter was found unsealed and undated. These deficiencies were identified during an observation with the Dietary Manager and had the potential to affect any resident consuming meals from the facility's kitchen.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident, identified as Resident #30, by not ensuring the availability of a call light within reach. Resident #30, who was admitted with diagnoses including legal blindness, major depressive disorder, schizoaffective disorder, and cognitive communication deficit, had a care plan that specified the need for a call light to be within reach due to her sensory and perception alterations. Despite this, observations revealed that the call bell was placed on a nightstand across the room, out of reach, and not accessible to the resident. Interviews with the resident and staff confirmed the deficiency. The resident expressed difficulty in locating the call bell at night due to her blindness. A CNA explained that the call bell was not in use because its cord would obstruct the walkway if positioned near the resident's bed. The RN confirmed the call bell's inaccessibility, attributing it to the absence of an extension cord, which the facility was awaiting. This situation left the resident to resort to yelling to communicate her needs.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #76, who has a history of mental health disorders including Bipolar Disorder, Schizophrenia, and Dementia, was physically abused by Resident #68. The incident occurred when Resident #76 tapped Resident #68 on the shoulder, causing Resident #68 to become frightened and grab Resident #76's hair. This resulted in Resident #76 falling to the ground. The facility's policy on abuse prevention, which includes protection from resident-to-resident abuse, was not effectively implemented in this case. Resident #68, who has a history of altercations and is diagnosed with Paranoid Schizophrenia and other mental health conditions, was involved in the altercation. The incident was reported by a CNA who witnessed the event and intervened to separate the residents. Despite the facility's awareness of Resident #68's history of altercations, the measures in place were insufficient to prevent the incident. The facility's failure to ensure adequate supervision and intervention led to the physical abuse of Resident #76.
Incomplete Investigation of Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation of an incident involving resident-to-resident abuse. On August 11, 2024, a Certified Nursing Assistant (CNA) reported that while distributing snacks in the special care unit's common area, one resident tapped another on the shoulder, causing the second resident to become frightened and grab the first resident's hair. During the altercation, the first resident fell to the ground. The residents were immediately separated, and the second resident was placed on one-to-one supervision before being sent to a behavioral hospital the following day. The facility's investigation into the incident was incomplete. Witness statements were not obtained from the CNA, a Licensed Practical Nurse (LPN), or the Registered Nurse (RN) on duty at the time of the incident. The facility also failed to conduct body audits and safety rounds on all residents in the behavioral unit. The administrator confirmed that the investigation was not completed and acknowledged the failure to obtain necessary witness statements from staff who observed the incident.
Failure to Implement Nutritional Interventions
Penalty
Summary
The facility failed to ensure a resident maintained acceptable nutritional status by not implementing appropriate interventions for weight loss. Specifically, the facility did not document the meal intake for a resident as care planned and failed to provide one-on-one assistance during meals. The resident, who had diagnoses including Major Depressive Disorder, Unspecified Dementia, Cellulitis, and Hypertension, experienced a significant weight loss of 17.15% over six months. The resident's care plan included interventions such as one-on-one dining assistance, monitoring food intake, and reporting any decline to the physician and dietician. Observations revealed that the resident was left unattended during meals, leading to unsafe eating behaviors, such as attempting to eat plastic wrap. The staff failed to document the resident's meal intake consistently, with numerous instances of missing documentation over several days. The Director of Nursing acknowledged these failures, confirming that the resident was care planned for one-on-one assistance with dining, which was not provided.
Failure to Maintain Resident's Personal Hygiene and Dignity
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity by not maintaining her personal hygiene, specifically by allowing her to have long, curly chin hairs. The resident, who has multiple diagnoses including Down's Syndrome, Major Depressive Disorder, and Dementia, was observed on multiple occasions with facial hair that was approximately an inch long, covering her entire chin. Despite being bathed regularly and not refusing personal care, the resident's facial hair was not addressed by the staff. Interviews with the facility's staff, including CNAs and the DON, confirmed that the resident had been observed with long chin hairs over several days. The staff acknowledged the need for the resident to be shaved, yet the issue persisted over multiple observations. The resident's care plan indicated she required assistance with personal hygiene, but this aspect of her care was neglected, impacting her dignity and quality of life.
Failure to Monitor and Record Food Intake
Penalty
Summary
The facility failed to implement the care plans for two residents, resulting in a deficiency related to monitoring and recording food intake. Resident #1, who has severe cognitive impairment and a history of weight loss, was not monitored for food intake as required by their care plan. The care plan included interventions such as dietician evaluation, determining food preferences, and monitoring food intake at each meal. However, the Meal Report revealed that food intake was not recorded on 36 out of 39 days, leading to a significant weight loss of 17% over three months. Similarly, Resident #2, who has multiple diagnoses including dementia and moderate intellectual disabilities, also experienced a failure in care plan implementation. The resident's care plan required monitoring and recording food intake at each meal, but the Meal Report showed that this was not done on 32 out of 39 days. This lack of documentation coincided with a significant weight loss of 12% over four months. The Director of Nursing acknowledged the failure to document meal intake for both residents as instructed in their care plans.
Failure to Maintain Safe Patient Care Equipment
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating condition for Resident #3. Resident #3, who has a history of hypertension, cerebrovascular disease, type 2 diabetes mellitus, and insomnia, was observed with a broken self-release belt buckle on his wheelchair. The resident, who has moderate cognitive impairment and impaired mobility, reported the broken buckle to a nurse but could not recall which nurse. Despite this report, the broken buckle was observed on multiple occasions over several days, indicating a failure to address the issue promptly. On two separate observations, the broken buckle was noted, and interviews with the resident and staff confirmed the issue. The LPN acknowledged that the buckle should not have been broken and that nursing staff are responsible for routinely monitoring the self-release belt. The facility administrator also confirmed the broken buckle, highlighting a lapse in maintaining essential equipment in safe working condition for the resident.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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